Summary: Mrs A complained about the standard of care and treatment in the care home where her mother Mrs X was resident. There is no evidence of fault in the standards of care and treatment but there was a delay in providing a prompt response to Mrs A’s complaint, for which the care provider has apologised

The complaint

1. Mrs A (the complainant) says the care provider failed to provide a safe standard of care for her mother Mrs X. In particular she complains that staff dropped Mrs X when a hoist failed and lost a swab which had been taken at the District Nurse’s request. She also complained that the home would not accept her mother back after a hospital admission. She says the actions of the care provider have caused considerable stress and anxiety.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C). If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
3. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

5. I considered evidence provided by Mrs A and the care provider as well as relevant law, policy and guidance.
6. Mrs A and the care provider had an opportunity to comment on my draft decision. I have considered Mrs A’s comments before making a final decision.

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What I found

Relevant law and guidance

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
8. Regulation 12 says care must be provided in a safe way for service users. It also says “where responsibility for the care and treatment of service users is shared with, or transferred to, other persons, [care providers are responsible for] working with such other persons, service users and other appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of service users”.
9. Regulation 16 says any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation.
10. Where it appears a person may be eligible for NHS Continuing Healthcare (NHS CHC), councils must notify the relevant integrated care system (ICS). NHS CHC is a package of ongoing care arranged and funded solely by the NHS where the individual has been found to have a ‘primary health need’ as set out in the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care. Such care is provided to people aged 18 years or over, to meet needs arising from disability, accident or illness.
11. The Mental Capacity Act 2005 introduced the “Lasting Power of Attorney (LPA)”. This replaced the Enduring Power of Attorney (EPA). An LPA is a legal document, which allows a person (‘the donor’) to choose one or more persons to make decisions for them, when they become unable to do so themselves.

What happened

12. Mrs X became resident in the care home in July 2023. She was admitted to a residential placement, so any nursing needs were met not by the home’s nursing staff (the home is also registered for nursing care) but by the District Nursing team.
13. Mrs X was described in her care plan as doubly incontinent and requiring a hoist for transfer as she had a weakness affecting all limbs, for which she regularly saw a physiotherapist. She frequently suffered from migraine and severe headaches. She was assessed as lacking capacity to make complex decisions about her care and treatment but able to make simple daily decisions. Care records show that she was frequently reluctant to drink enough fluids and that care staff regularly had to remind her.
14. In September 2023 Mrs X was involved in an incident when the hoist strap failed. The carer’s notes read, “accident involving (Mrs X) falling from the hoist.  (Mrs X) was on the floor lying on her left side, head facing the door and feet facing the window on the right side of her bedroom door.  (Mrs X) in good spirits despite being on the floor… insisted that she had not hurt herself.  Carer advised that she had took (Mrs X)'s weight when the hoist had failed and lowered (her) to the floor and prevented any injury. (Mrs X) was hoisted back to bed and made comfortable…. checked regularly and …continues to insist that she is OK.  No visual or physical injury noted.” Mrs X was observed closely over the next 24 hours but there were no consequences from the fall.
15. In April 2024 care staff noticed a vaginal discharge and contacted the District Nurse team on 4 April to take a swab. Daily care notes for 10 April show the home was still waiting for the District Nurses to attend to take a swab. Notes for 14 April say Mrs A had asked about the swab: she said she had checked with the GP surgery who had no record. The care staff said they would check again with the GP surgery but it appeared not to have been taken yet. On 15 April an agency nurse took the swab (after checking with the senior nurse in charge) and sent it to the surgery for analysis. Despite regular checks by the care home staff it was 19 April before a prescription for antibiotics was provided by the GP surgery and 20 April before the antibiotics were available.
16. There were increasing concerns about Mrs X’s condition, particularly as she started often refusing fluids and sometimes declined food and personal care. In May Mrs A was assessed for CHC funding but found not to be eligible. The care notes record that Mrs A, who had not previously been notified of the assessment, was annoyed that she had not been involved as she held lasting Power of Attorney for her mother.
17. Over the next few days after the CHC assessment, Mrs A became more unwell and started vomiting frequently. The care home decided to call an ambulance when there was a slow response from the GP and Mrs A was admitted to hospital on 8 May.
18. The care home records for 9 May show the care home manager contacted the hospital and said Mrs A needed a reassessment before discharge as there were concerns she now required a nursing and not a residential placement. The manager explained to the hospital staff that the home had started an assessment prior to the hospital admission. Notes for 28 and 29 May indicated that Mrs X was seen by the complex care team and it was decided her needs could no longer be met in her currently placement.

The complaint

19. In July Mrs A complained to the care provider. She asked for all notes and documentation in respect of the fall from the hoist, a lost urine sample in November, failure to take a full blood count in March 2024 when a nurse suggested Mrs X had anaemia, suspected loss of a vaginal swab in early April 2024, failure to involve her in the CHC assessment in May, and failure to act sooner on Mrs X’s deterioration. She asked for the reasons why she was told the home could no longer meet Mrs X’s needs.
20. The care home manager sent Mrs A some but not all of the documents she had requested. It did not provide a substantive response to her complaint until January 2025, after Mrs A complained to the Ombudsman.
21. In its response the care provider accepted it had not sent all the documents requested and undertook to do so. It explained it did not hold the notes made by visiting staff such as the District Nurse team
22. The care provider said Mrs X had not been dropped from the hoist. It said the strap had failed but fortunately this was immediately apparent and the carer in attendance had carefully guided the hoist, with Mrs X in it, to the floor and she was unharmed.
23. The care provider said there was no record of a urine sample being requested or taken in November. A sample had been taken in December and was routinely analysed and came back clear. Mrs A says “The urine sample in November was taken and I physically walked with the manager at the time & she found it in the fridge”.
24. The care provider said the blood tests requested in March 2024 were requested by the District Nurse team, not the care home, and it was their decision which tests were requested.
25. In respect of the vaginal swab, the care home staff had followed up the request for this with the District Nursing team but the delay was theirs, not that of the care home staff.
26. The care provider said Mrs A should have been notified about the CHC assessment but added that it was not always the case that the care home team were notified in advance by the CHC team (although Mrs A says this appointment was in the home’s diary). She said at that point Mrs X was not deemed eligible for either Funded Nursing Care or Continuing Health Care funding.
27. Finally, the care provider said at the point when Mrs X was ready for discharge from the hospital the care home manager felt her needs could no longer be met in the home. It said, “This was because the Lodge felt that it would not be safe to bring her back into the Lodge based on the residents in the Lodge and whilst it was in its growth phase. This was also based on information received from the hospital”. It added, “ At no point was any treatment delayed nor did the Lodge act inappropriately. This was also confirmed when the circumstances were investigated by the safeguarding team.”

Analysis

28. Mrs X’s health deteriorated in the last few weeks she was resident in the care home but I have not seen any evidence that there was a delay in obtaining medical advice. Mrs X was regularly seen by nursing staff and when care staff were concerned about her condition there is evidence they took appropriate steps to escalate their concerns.
29. There is no evidence that Mrs X “fell” from the hoist and Mrs A acknowledges her mother suffered no harm as a result of this incident. The care provider has provided photographs of how the hoist strap failed. I do not see evidence of fault here.
30. There was some confusion over the swabs and samples which were ordered. Mrs A says a urine sample taken in November was left in the fridge and could not be used. The notes do not show evidence that a sample was requested or taken then but there was a sample taken in December. In any event I do not see any harm ensued as a result. The swab taken in April was not delayed by the care home staff but because of a delay on the part of the District Nursing team. The care notes show this was regularly pursued by the care home staff.
31. It is unfortunate that Mrs A was not notified of the CHC assessment visit and the care provider acknowledged that. Mrs X was not deemed eligible at that time and I do not see any injustice was caused as a result.
32. It was a matter for the care provider to decide whether it could meet Mrs X’s needs on discharge from hospital. I have not seen evidence that there was any other reason why it said it could not do so.
33. The care provider should have responded sooner and more fully to Mrs A’s concerns. Its failure to do so caused her additional stress and anxiety and the care provider should acknowledge that.

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Action

34. Within one month of my final decision the care provider should review its complaints processes to ensure it complies with the guidance and responds promptly to complaints.
35. Within one month of my final decision the care provider should apologise to Mrs A for the delay and offer £300 in recognition of the additional stress and anxiety the delay caused.
36. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

I find evidence of some fault which caused injustice to Mrs A, which will be remedied by the completion of the recommendations at paragraph 34 and 35 above.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman